CBL cases Flashcards
1
Q
General enquiry for paediatric patients
A
- feeding
- activity
- sleep
- temperament
2
Q
Important features in a paediatric history specifically
A
Maternal history:
- antenatal: scan abnormalities, infections
- perinatal: gestation, delivery, complications
- postnatal: time in SCBU, neonatal sepsis
Developmental history
Immunisations
SHx: smokers in the house, social worker involvement, family and school life
FHx: congenital heart/hip/kidney disease, consanguinity
3
Q
Which murmurs in children are never innocent
A
Diastolic
4
Q
Common urine dip finding in febrile children
A
Raised protein - transient proteinuria in febrile illnesses
5
Q
Vaccinations at 8 weeks
A
6 in 1 (diphtheria, hep B, Hib, polio, tetanus, whooping cough
Rotavirus
MenB
6
Q
Timing for late-onset GBS sepsis
A
Up to 3 months after birth
7
Q
When would you give steroids in meningitis
A
Never <3 months of age Give dexamethasone if >3 months and: - frankly purulent CSF - WCC>1000 - raised WCC + protein + bacteria on gram stain
8
Q
Important differential if fever >5 days
A
Kawasaki disease
9
Q
How to differentiate between a rigor and a febrile convulsion
A
Consciousness
10
Q
Causative organism in Scarlet fever
A
Streptococcus pyogenes (Group A beta-haemolytic strep) Normally present in nasopharynx but may cause tonsillitis or pharyngitis (Scarlet fever evolves from this)
11
Q
Spread of Scarlet fever
A
Respiratory droplet spread
12
Q
Incubation period for Scarlet fever - when are they contagious?
A
1-7 days
During the active illness and the incubation period
13
Q
Common age for Scarlet fever
A
Age 2-10 years (unlikely under 2 due to maternal antibody protection)
14
Q
Common presentation of Scarlet fever
A
Sudden onset fever with tachycardia followed by typical rash 24-48 hours later
White strawberry tongue which then sheds (desquamation) to red strawberry tongue
Peeling skin of fingers and toes especially
15
Q
Typical rash in Scarlet fever
A
Generalised erythema with pin-point, dark red spots overlying and a coarse/sandpaper texture
Typically affects neck, chest and scapular regions first before spreading to trunk and legs
Circumoral pallor
16
Q
Treatment for Scarlet fever
A
Antibiotics - penicillin or azithromycin for 10 days
Rest and adequate fluids
Ibuprofen/paracetamol for symptom relief
17
Q
What is Kawasaki disease
A
Systemic, autoimmune mediated vasculitis affecting small and medium sized vessels
Also known as mucocutaneous lymph node syndrome
18
Q
Where is Kawasaki disease most common
A
Japan (and East Asia)
19
Q
Diagnostic criteria for Kawasaki disease
A
Fever for >5 days and 4 of the following:
1. conjunctivitis
2. mucous membrane changes (e.g. strawberry tongue, dry and cracked lips)
3. cervical lymphadenopathy
4. widespread erythematous maculopapular rash
5. desquamation or oedema of feet/hands
Children will be very irritable
20
Q
Phases of Kawasaki disease course of illness
A
Acute (1-2 weeks) - child is most unwell with fever, rash and lymphadenopathy
Subacute (2-8 weeks) - acute symptoms settle, skin peels and arthralgia sets in. Risk of CAAs
Convalescent (months+) - resolution of symptoms and biochemical results. Cardiac dysfunction may still occur
21
Q
Most important possible complication of Kawasaki disease
A
Cardiac complications - coronary artery aneurysms
22
Q
Treatment for Kawasaki disease
A
Aspirin + IV immunoglobulin
Follow up with echocardiograms
23
Q
Where is group B strep commonly found
A
Vagina and rectum (20-40% of women in the UK)
24
Q
Risk of baby developing GBS infection if found by vaginal swab at 35-37 weeks gestation
A
1 in 500
Higher risk if GBS detected in urine
25
3 complications of GBS infection in newborns
Sepsis
Pneumonia
Meningitis
26
Risk factors for early-onset neonatal GBS infection
- intrapartum fever (>38C)
- prematurity (<37/40)
- prolonged ROM (>18hrs)
- known GBS carrier
- previous infant with GBS infection
- GBS UTI during current pregnancy
27
Intrapartum management of GBS
Intrapartum abx prophylaxis (prevention of early-onset neonatal infection) - IV BenPen
28
Postpartum management of GBS
Measure CRP of babies starting abx
IV BenPen with gentamycin
?stopping abx at 36 hours if showing signs of response
29
Definition of Henoch-Schonlein purpura (HSP)
IgA-mediated autoimmune hypersensitivity vasculitis of childhood
30
Clinical features of HSP
```
Skin purpura
Arthritis
Abdo pain
GI bleeding
Nephritis
```
31
Description of typical rash in HSP
Begins as red spots/bumps (hive-like appearance) rapidly changes to small, dark, purple bumps (palpable purpura) within first 24 hours
Lower legs, buttocks, elbows and knees
Symmetrical distribution
32
Treatment for HSP
Normally self-limiting condition therefore supportive treatment and prevention of complications
Monitor renal function - blood pressure, urinalysis, U&Es
33
Renal involvement in HSP
Up to 55% of children but is generally mild
| Ranges from microscopic haematuria and mild proteinuria to nephrotic/nephritic syndrome and renal failure
34
Prognosis for HSP
Generally self-limiting and resolves within 4 weeks
| Prognosis depends on severity of renal involvement
35
Definition of febrile convulsion
Seizures which occur in response to a rapid rise in temperature (fever >38C)
36
3 classifications of febrile convulsion
1. simple febrile seizure
2. complex febrile seizure
3. febrile status epilepticus
37
Features of simple febrile seizure
Tonic clonic seizure lasting <15 mins
Don't reoccur within 24hrs or within same febrile illness
No long-term neuro effects, no increased risk of epilepsy
38
Features of complex febrile seizure
Features of focal seizure
Lasts >15 mins
Reoccur within same febrile illness
39
What is febrile status epilepticus
Febrile seizure lasting >30 mins
40
Risk factors for reoccurrence of febrile seizure
- young age at first seizure
- first seizure occurs early in course of infection
- low temp at first seizure (low threshold)
- FHx
41
Differentials for seizures in children
```
Epilepsy
Head injury
Encephalitis
Hypoglycaemia
Hyperglycaemia
```
42
Common infections causing febrile seizures
Otitis media
Viral infections
Tonsillitis
43
Description of tonic-clonic seizure
Tonic phase = body is stiff and rigid for up to 60 seconds, incontinence and tongue biting may occur
Clonic phase = generalised convulsions and limb jerking
44
Management approach for simple febrile convulsions
Parental education and reassurance
Antipyretics in febrile illnesses, removal of excess clothing
Timing and describing seizure
45
Management of prolonged febrile seizure (>5 mins)
Rectal or buccal diazepam
| Repeat at 5 mins
46
When to suspect (and treat) meningitis in a febrile seizure
```
Systemically unwell, irritable or drowsy before seizure
GCS <15 one hour after
Neck stiffness
Non-blanching rash
Bulging fontanelle
```
47
Treatment of meningococcal disease
BenPen or cefotaxime
48
Criteria for moderate acute asthma in children
- able to talk in sentences
- oxygen over 92%
- peak flow over 50% best/predicted
- HR <140 (age 1-5) or <125 (5+)
- RR <40 (age 1-5) or <30 (5+)
49
Criteria for severe acute asthma in children
- can't complete full sentences
- oxygen under 92%
- peak flow 33-50% best/predicted
- HR >140 (age 1-5) or >125 (5+)
- RR >40 (age 1-5) or >30 (5+)
50
Criteria for life-threatening acute asthma in children
- exhaustion
- hypotension
- cyanosis
- silent chest
- poor resp effort
- confusion
- peak flow <33% best/predicted
- oxygen under 92%
51
What is stridor
Inspiratory wheeze caused by an upper airway obstruction
52
Management of mild croup
Oral dexamethasone 0.15mg/kg single dose
53
Management of moderate croup
Oral dexamethasone 0.15mg/kg single dose and observe in ED for 2-3 hours
If worsening symptoms give nebulised adrenaline 5ml of 1:1000 and observe
54
Management of severe croup
Nebulised adrenaline 5ml of 1:1000 and oral/IV dexamethasone 0.15mg/kg
Oxygen by facemask
55
Definition of bronchiolitis
Inflammation and infection in the bronchioles (LRTI)
56
Cause of bronchiolitis
Respiratory syncytial virus (RSV) most commonly
57
What age group gets bronchiolitis
Under 6 months most common
Under 1 year old
Age 1-2 more rare, in children with underlying lung disease
58
Risk factors for severe disease in bronchiolitis
```
Prematurity
Low birth weight
Mechanical ventilation as a neonate
Age <12 weeks (now)
Medical conditions: chronic lung disease, congenital heart disease, neuro disease, epilepsy, diabetes, immunocompromise, congenital airway defects, Downs
```
59
Pathophysiology of bronchiolitis
Virus invasion and inflammatory response causes swelling and mucus of the small airways. Young children have very small airways to begin with therefore this change causes significant impact on their breathing ability.
60
Course of illness in bronchiolitis
Begins as URTI - coryzal symptoms
Chest symptoms day 1-2
Peak of symptoms day 3-4
Symptoms generally resolve day 7-10
61
What are the signs of respiratory distress in infants
```
Raised resp rate
Use of accessory muscles and head bobbing
Intercostal and subcostal recession
Tracheal tug
Grunting
Nasal flaring
Cyanosis
```
62
What is heard on auscultation of the chest in bronchiolitis
Wheeze and crackles
63
How may very young infants present differently in bronchiolitis
May present with apnoeas (periods of no breathing) and no other signs
64
Criteria for admission in bronchiolitis
- aged <3 months
- pre-existing conditions e.g. Downs, prematurity, CF
- decreased feeding <75% normal
- clinical dehydration
- RR >70
- oxygen <92%
- respiratory distress
- apnoeas
- parents unable to cope/ living far from medical care
65
What is the general approach to managing bronchiolitis
Supportive - reassurance to parents, fluid intake, nasal suctioning if needed
66
When to give supplementary oxygen in bronchiolitis
Sats consistently below 92%
67
Criteria for discharge after bronchiolitis admission
- clinically stable
- taking adequate oral fluids
- maintaining oxygen over 92% in air for >4 hours including a period of sleep
68
Immunoprophylaxis for bronchiolitis
Palivizumab (monoclonal antibody) - gives passive immunity to those at high risk of developing severe disease
69
Definition of viral-induced wheeze
Acute wheezy illness caused by viral infection
70
Cause of viral-induced wheeze
Respiratory syncytial virus (RSV)
71
Pathophysiology of viral-induced wheeze
Virus infection and inflammatory response leads to inflammation and oedema in airways. Also causes bronchoconstriction.
72
Difference between viral-induced wheeze and bronchiolitis
Viral-induced wheeze most common aged 1-3 whereas bronchiolitis is most common under 1
Viral-induced wheeze shows bronchoconstriction whereas bronchiolitis is 'wet lungs' i.e. mucus/oedema
This is related to the child's developing immune system and different immune responses at different ages
73
How to distinguish between asthma and viral-induced wheeze
Asthma isn't commonly diagnosed before age 5, VIW is most common under 3
Asthma shows atopic history, VIW doesn't
VIW only occurs during viral infections whereas asthma is likely to have other triggers such as cold weather, dust, exercise`
74
Definition of asthma
Chronic inflammation of the bronchial mucosa and hyper-reactive airways resulting in bronchoconstriction and reversible airway narrowing
75
Differentials for asthma in chidlren
Transient early wheezers/ viral-induced wheeze (associated with viral infection, aged under 3)
Non-atopic wheezers (resolves by age ~5)
76
What is the management of viral-induced wheeze
Same as management of acute asthma in children
77
First-line treatments for acute asthma in children
1. Oxygen (if <94%)
2. Salbutamol
- MDI + spacer: 10 puffs (100mcg)
- nebs if needing O2: 2.5-5mg
3. Ipratropium bromide
- 250mcg nebs
4. Steroids
- oral prednisolone 10-40mg depending on age
78
Second-line treatments for acute asthma in children (not responding to first-line methods)
1. IV salbutamol
- IV bolus of 15mcg/kg over 10 mins
- cont. IV infusion 1-2mcg/kg/min
2. IV aminophylline
- 5mg/kg bolus over 20 mins followed by cont. infusion at 1mg/kg/hr
3. IV mag sulph (preferred)
- up to 75mg/kg/day
79
Description of the wheeze heard in asthma
Expiratory polyphonic wheeze
80
4 tests used to investigate and diagnose suspected asthma in children
1. fractional exhaled nitric oxide (FeNO)
2. obstructive spirometry
3. bronchodilator reversibility test
4. peak flow variability
81
Level of FeNO which may indicate asthma diagnosis
35ppb (parts per billion) or more
82
What is fractional exhaled nitric oxide and why is it useful
FeNO
NO is produced by cells involved in the inflammation associated with atopic asthma therefore measuring this gives an idea of how much inflammation is occurring and how severe the atopic asthma is
83
Result of obstructive spirometry which may indicate asthma diagnosis
FEV1/FVC ratio <70%
84
Result of bronchodilator reversibility test which may indicate asthma diagnosis
Improvement in FEV1 of >12%
85
Result of peak flow variability testing which may indicate asthma diagnosis
Variability over 20%
86
Step-up algorithm to management of chronic asthma in children over 5
1. SABA as required (salbutamol)
2. regular preventer - low dose inhaled corticosteroids (ICS)
3. add LABA (salmeterol) or LTRA (montelukast)
4. increase ICS or add remaining LABA/LRTA
5. refer to specialist, consider stopping LABA
87
Which trisomy is related to Downs syndrome
21 (extra chromosome)
88
Clinical features of Downs syndrome often spotted at birth
- hypotonic
- flat occiput
- single palmar creases
- incurved fifth finger
- wide 'sandal' gap between big and second toes
89
Most common mechanism leading to trisomy 21
```
Meiotic nondysjunction (94%)
Related to maternal age
```
90
Craniofacial appearance of Downs syndrome
- round face and flat nasal bridge
- upslanted palpebral fissures
- epicanthic folds
- brushfield spots in iris
- small mouth and protruding tongue
- small ears
- flat occiput and third fontanelle
91
Medical problems associated with Downs syndrome which may be present at birth
- congenital heart disease (40%)
- duodenal atresia
- Hirschsprung disease
92
Medical problems associated with Downs syndrome which may come later on in life
- delayed motor milestones
- learning difficulties
- short stature
- increased susceptibility to infections
- hearing impairment from secondary otitis media
- visual impairment
- obstructive sleep apnoea
- epilepsy
- early onset Alzheimer's
93
2 tests (after birth) to investigate for Downs syndrome
Rapid PCR
| Rapid fluorescence in situ hybridization (FISH)
94
Which trisomy is associated with Edwards syndrome
Trisomy 18
95
Clinical features of Edwards syndrome
- low birth weight
- prominent occiput
- small mouth and chin
- short sternum
- flexed, overlapping fingers
- rocker-bottom feet
- low-set and malformed ears
- microcephaly
- cleft lip and palate
- malformation of sex organs
96
Complications associated with Edwards syndrome
Most die before or shortly after birth
- congenital heart defects (>90%)
- GI abnormalities e.g. hernia, pyloric stenosis
- UG abnormalities e.g. horseshoe kidney, hydronephrosis
- neuro e.g. hydrocephaly, severe learning disability
- central apnoea (can cause death)
97
Trisomy associated with Patau syndrome
Trisomy 13
98
Clinical features of Patau syndrome
- scalp defects
- small eyes and other eye defects (cyclops)
- cleft lip and palate
- polydactyly
- malformation of sex organs
- ear malformations
- rocker-bottom feet
99
Complications associated with Patau syndrome
Most die before or shortly after birth
- congenital heart defects (80%)
- severe learning disability
- central apnoea
- hearing impairment
- GI abnormalities e.g. hernia
- UG abnormalities e.g. polycystic kidneys
100
2 types of breath holding spells in children
1. cyanotic/blue breath holding spells
| 2. reflex anoxic seizures
101
Description of a cyanotic/blue breath holding spell
An episode in which upset toddlers cry and (involuntarily) hold their breath on expiration leading to cyanosis. The child may lose consciousness but recovers quickly.
102
Description of a reflex anoxic seizure
After a trigger (e.g. pain, discomfort, minor head trauma, fright or fever), the vagus nerve sends strong signals to the heart to stop beating leading to pallor and loss of consciousness. Hypoxia may induce a tonic-clonic seizure but it is brief.
103
What is hyperekplexia
Whole body stiffening in response to a sudden noise or being touched/handled. Can be terminated by forced flexion of the neck.
104
Symptoms of reflux in babies
- bringing up milk or being sick shortly after feeds
- coughing/hiccupping during feeds
- unsettled during feeding
- swallowing or gulping after burping or feeding
- not gaining weight (not keeping food down)
105
When can children with chicken pox return to school
After all vesicles have crusted over
106
When can children with rubella return to school
After four days from onset of rash
107
When can children with impetigo return to school
After lesions are crusted and healed or after 48 hours of antibiotics
108
When can children with measles return to school
After four days from onset of rash
109
When can children with Scarlet fever return to school
After 24 hours of antibiotics
110
Which paediatric rashes/skin infections don't need to have time off school
Hand, foot and mouth
Molluscum contagiosum
Roseola infantum
Slapped cheek (fifth disease/parvovirus B19)
111
Presentation of measles
- prodrome of fever, malaise, anorexia, conjunctivitis, cough and coryzal symptoms
- Koplik spots in mouth
- rash: flat, red, non-itchy spots beginning on face and behind ears and may spread over whole body with palm/sole sparing
112
What is immune thrombocytopaenia
Autoimmune condition leading to depleted platelet levels due to antibody production against platelets. May follow viral infection or (more rarely) vaccination.
113
Common presentation of immune thrombocytopaenia
Petechiae or bruising of skin
Can show no symptoms, mild bleeding issues e.g. nosebleeds, haematuria or progress to GI bleeds or life-threatening intracranial haemorrhage
114
Treatment for immune thrombocytopaenia
Most are mild and self-resolving just needing platelet monitoring and safety netting around trauma prevention and avoiding NSAIDs and aspirin
If more severe: pred, IV Ig, IV anti-D Ig, rituximab, dexamethasone
Emergency platelet transfusion if needed
115
Benefits of breastfeeding for the baby
Reduces risk of:
- infections
- D&V
- sudden infant death syndrome
- obesity
- CVD (adulthood)
- necrotising enterocolitis
- childhood leukaemia
116
Benefits of breastfeeding for mother
Reduces risk of:
- breast cancer
- ovarian cancer
- osteoporosis
- CVD
- obesity
- T2DM
117
Risk factors for developing neonatal jaundice
- preterm
- ethnicity: Asian, European, Native American
- newborn factors: visible jaundice <24hrs of life, gestation <38/40, male, visible bruising
- maternal factors: DM, >25y/o, exclusive breast feeding
- previous sibling needing phototherapy
118
epidemiology of physiological jaundice in newborns
- occurs between day 2 and 10 of life
- no underlying cause
- breastfed > bottle fed
119
How to distinguish physiological jaundice biochemically
Physiological jaundice is always unconjugated
120
Pathophysiology of physiological jaundice in the newborn
- neonates have a shorter RBC lifespan therefore bilirubin levels are higher
- metabolism and excretion of bilirubin is slower
- immature liver in preterm babies
121
Criteria indicating abnormal (pathological) jaundice
- occurs <24h birth
- lasts >14 days in term babies
- lasts >21 days in preterm babies
122
Underlying disorders which cause jaundice due to increased bilirubin production
- blood group incompatibility (ABO, Rhesus)
- G6P deficiency
- IVH
- cephalohaematoma
- polycythaemia
- sepsis -> DIC
- bruising
123
Underlying disorders which cause jaundice due to decreased bilirubin clearance
- extrahepatic biliary atresia
- neonatal cholestasis: alpha-1-antitrypsin deficiency, cystic fibrosis
- inborn errors: Gilbert syndrome, Crigler-Najjar syndrome
- hypothyroidism, hypopituitarism
124
Differentials for unconjugated jaundice in neonates
- breastmilk jaundice
- infection (UTI)
- haemolysis (blood group incompatibility, G6PD)
- hypothyroidism
- high GI obstruction
- Crigler-Najjar syndrome
125
Differentials for conjugated jaundice in neonates
- biliary atresia
- choledochal cyst
- congenital infection
- inborn errors
- alpha1-antitrypsin
- galactosaemia
- cystic fibrosis
126
Diagnostic levels for unconjugated and conjugated hyperbilirubinaemia
Unconjugated hyperbilirubinaemia = >80% total bilirubin is unconjugated
Conjugated hyperbilirubinaemia = >20% of total bilirubin is conjugated
127
How does phototherapy work for neonatal jaundice
Blue-green light converts unconjugated bilirubin in water soluble molecules that can be excreted
128
Definition of prolonged jaundice
Jaundice lasting >14 days in term babies or >21 days in preterm babies
129
Investigations for prolonged jaundice
- general assessment: feeding, weight, stool and urine colour
- (if well) split bilirubin test
- if split test shows a hyperbilirubinaemia (unconjugated or conjugated) refer to paediatrician for further testing
130
Further testing for conjugated hyperbilirubinaemia
- repeat split bilirubin
- LFTs
- blood glucose
- coagulation
131
6 common congenital birthmarks
- congenital melanocytic naevi (brown birthmark)
- cafe au lait spots
- mongolian spots
- haemangioma
- macular stains/salmon patches
- port-wine stain
132
Description of congenital melanocytic naevus`
Single- or multi- shaded, round- or oval- shaped, patches. May have increased hair growth (hypertrichosis)
133
Description of cafe au lait spots and important note
Hyperpigmented skin patch with sharp border and diameter of >0.5cm
Up to 3 are normal in Caucasians, up to 5 are normal in Afro-Caribbean's - any more may indicate neurofibromatosis
134
Description of Mongolian blue spots
Bluish-grey patches commonly found on back or buttocks
135
Description of Macular stains/Salmon patches
Small, flat patches of pink or red skin with poorly defined borders
136
Description of haemangioma (strawberry naevus)
Raised, pink or purple patch with clearly defined border. Waxy look and surface may contain telangiectasia.
137
Description of port-wine stain
Large, flat patch or purple or dark red skin with well-defined borders. Begins as flat surface but may become more bumpy.
138
in which age group is appendicitis most common
age 10-20
139
how does appendicitis present in children
acute abdo pain
classic pain distribution not as common and may be vague
watery diarrhoea and vomiting in infants
140
management of appendicitis in children
appendicectomy if high clinical suspicion
| antibiotic treatment: cefuroxime and metronidazole
141
complications of appendicitis
perforation and peritonitis
appendix mass
abscesses
wound infection
142
what is mesenteric adenitis
inflammation of the lymph nodes in the abdomen
143
common age for mesenteric adenitis presentation
under 16yo
144
what causes mesenteric adenitis
viral infection commonly
| more rarely bacterial infection
145
common presentation of mesenteric adenitis
mild abdo pain
following period of coryzal symptoms/viral illness e.g. sore throat, runny nose
may have fever, malaise, nausea, diarrhoea
146
management of mesenteric adenitis
analgesia and rest (viral illness)
| if bacterial, antibiotics accordingly
147
what is intussusception
telescoping or invagination of a section of bowel into a distal segment, leading to obstruction
148
risk factors for intussusception
- male gender
- conditions pre-disposing e.g. Meckel's diverticulum, polyps, haemangiomas, tumours, appendix inflammation, CF, coeliac, Crohn's
- viral infection
- rotavirus vaccine
149
common age of presentation of intussusception
under 1yo
| peak age 5-10 months
150
example of a non-pathological lead point in intussusception
viral infection e.g. rotavirus, adenovirus
151
example of a pathological lead point in intussusception
pre-existing condition:
- Meckel's diverticulum
- HSP
- lymphoma
- CF
152
common presentation of intussusception
sudden onset colicky abdominal pain (waves every 10-20 mins)
- bile stained vomiting
- redcurrant jelly stools
- palpable 'sausage-shaped' mass often in RUQ
153
key ultrasound finding in intussusception
doughnut/target sign
154
management of intussusception
- resuscitation ('drip and suck'): IV fluids and NG tube
- radiological intervention: air or barium enema
- laparotomy to reduce or resect bowel if peritonitic/perforated
155
complications of intussusception
ischaemia and necrosis of the bowel
sepsis, septicaemia
haemorrhage
perforation and peritonitis
156
management of paediatric constipation
- acute disimpaction using osmotic laxatives
- reassurance and advice to parents and child
- diet and lifestyle modifications: fluid, fibre, exercise
- behavioural modifications
- consider child abuse (neglect)
157
what is testicular torsion
torsion or twisting of the spermatic cord causing occlusion of testicular blood vessels
158
what structural abnormality is associated with testicular torsion
'Bell-clapper' deformity = lack of normal fixation of posterolateral aspect of tunica vaginalis meaning testes are free to swing and rotate within TV
159
which testicle is more commonly affected by torsion
LHS
160
common presentation of testicular torsion
- sudden, severe pain and swelling in one testis with redness of skin
- lower abdo pain, N&V
- onset often during sport or physical activity
161
clinical sign indicating testicular torsion
absence of cremasteric reflex (stroking of inside thigh causes retraction of testis on same side - not present)
162
2 types of testicular torsion and associated group who gets it
intravaginal - Bell-clapper deformity
| extravaginal - neonates
163
first-line investigation for testicular torsion
US integrated with colour doppler
164
management of testicular torsion
possible manual reduction (outwards rotation) should see immediate relief - if not, emergency surgical intervention and bilateral orchiopexy
orchidectomy may be required if testicle is no longer viable
165
complications of testicular torsion
infarction and necrosis of affected testicle - possible orchidectomy required (prosthesis fitted)
subfertility or infertility - unlikely if still have remaining testicle
166
definition of meningitis
inflammation of the meninges
167
aetiology of meningitis
caused by viral infection more commonly (generally less severe) but can be caused by bacteria (more severe - bacterial until proven otherwise)
168
common causative bacteria in neonatal meningitis
- group B strep
- listeria monocytogenes
- e. coli
169
common causative bacteria of meningitis in infants and young children
- haemophilus influenzae type B (HIB)
- neisseria meningitidis (<4, not vaccinated)
- strep pneumoniae
170
common causative bacteria of meningitis in adults and older children
- strep pneumoniae
- HIB
- neisseria meningitidis
- gram-neg bacilli e.g. klebsiella, pseudomonas
171
common symptoms of meningitis
- stiff neck (uncommon in <1yo or low GCS)
- non-blanching rash
- back rigidity
- photophobia
- leg pain
172
common signs of meningitis
- non-blanching rash
- bulging fontanelle (infants)
- CR >2s, cold peripheries
- unusual skin colour
- altered mental state
173
what is Kernig's sign
meningitis - pain and resistance on passive knee extension with hips fully flexed
174
what is Brudzinski's sign
meningitis - hips flex on bending the head forward
175
management of meningitis
- supportive treatment with analgesia, antipyretics, nutritional support and hydration
- metabolic/circulatory disturbances corrected
- antibiotics (blind therapy then confirmed)
- if older than 3 months, give dexamethasone stat
176
dose of dexamethasone for meningitis
(>3m)
| 0.15mg/kg (max 10mg) QDS for 4 days
177
what is the initial blind abx therapy for meningitis
under 3 months old: cefotaxime + ampicillin/amoxicillin IV
| over 3 months old: ceftriaxone IV
178
abx management of n. meningitidis meningitis
7+ days IV ceftriaxone
179
abx management of s. pneumoniae meningitis
14 days IV ceftriaxone
180
abx management of hib meningitis
10 days IV ceftriaxone
181
abx management of group b strep meningitis
14+ days IV cefotaxime
182
abx management of listeriosis meningitis
7 days IV amoxicillin/ampicillin + gentamycin then further 14 days IV amoxicillin/ampicillin
183
bloods to order in suspected meningitis
FBC, CRP, coagulation screen, blood culture, PCR for n. meningitidis, blood glucose, ABG, U&E
184
other investigations (not bloods) to order in suspected meningitis
- lumbar puncture
- CXR
- urine culture
- nasopharyngeal swabs
- stool virology
- CT is adverse clinical features
185
when is lumbar puncture contraindicated in suspected meningitis
- signs of increased intracranial pressure e.g. reduced consciousness, extreme headache, frequent fits
- focal neurology
- severe shock/sepsis
186
definition of pneumonia
infection of the lung tissue which causes inflammation and filling of sputum in the alveoli
187
risk factors for pneumonia in children
- <5yo
- premature (24-28 weeks gestation)
- seasonal variation: peaks in december and august
188
common causative organisms for pneumonia in newborns
- GBS
- gram-neg enterococci and bacilli
- myobacterium tuberculosis
189
common causative organisms for pneumonia in infants and young children
- RSV
- parainfluenza
- influenza
- strep. pneumoniae
- h. influenza
- staph. aureus
- mycobacterium tuberculossi
190
4 common causative organisms for pneumonia in children older than 5
- mycoplasma pneumonia
- strep. pneumonia
- chlamydia pneumonia
- mycobacterium tuberculosis
191
common symptoms of pneumonia
- high fever (>39)
- cough (wet and productive)
- increased WOB
- lethargy
- poor feeding
- delirium
- generally unwell
192
common signs of pneumonia
- tachypnoea
- tachycardia
- hypoxia (<95%)
- cyanosis
- focal coarse crackles
- decreased breath sounds
- bronchial breathing
- dullness of percussion
- signs of resp distress
193
investigations to order for suspected pneumonia
- obs
- nasopharyngeal aspirate for viral PCR and bacterial cultures
- FBC, CRP
- blood cultures
194
management of pneumonia at home
- antipyretics
- fluids to prevent dehydration
- safety netting
- course of antibiotics
195
management of pneumonia in hospital
- oxygen therapy by nasal cannula or face mask (aim >92%)
- fluids (oral -> NG -> IV)
- antibiotics
196
abx choice in pneumonia
first line = amoxicillin 7-14 day
penicillin allergic or atypical = ...thromycin
oral unless not tolerated or signs of septicaemia
197
what is pyloric stenosis
hypertrophy of the pyloric muscle causing obstruction of the gastric outlet
198
risk factors for pyloric stenosis
- male
- maternal FHx
- affected siblings
199
common symptoms of pyloric stenosis
2-8 weeks of age
- projectile vomiting in otherwise well child after feeding
- continuous hunger after vomiting
- weight loss/poor weight gain, failure to thrive
- dehydration late stage
200
common signs of pyloric stenosis
- peristalsis observed in abdomen
- firm, olive shaped mass felt in RUQ
- signs of dehydration
201
ABG finding in pyloric stenosis
metabolic alkalosis with hypochloraemic and hypokalaemic state
202
investigations to do in suspected pyloric stenosis
- abdo exam shows olive shaped mass in RUQ
- test feed to show wave of peristalsis and projectile vomiting
- ABG
- USS shows thickened pyloric muscle (>4mm)
- barium meal shows string sign of elongated and narrowed pyloric sphincter
203
management of pyloric stenosis
- correct fluid and electrolyte imbalances
- insert NG tube to decompress stomach
- laparoscopic pyloromyotomy
204
how is weight faltering defined
sustained drop of two centiles or below the 0.4th centile or BMI <2nd centile
205
5 categories for causes of weight faltering
1. inadequate intake
2. inadequate retention
3. malabsorption
4. failure to utilize nutrients
5. increased requirements
206
examples of inadequate intake causing weight faltering
- availability of food
- psychosocial deprivation e.g. maternal depression or interaction
- neglect or child abuse
- impaired suck/swallow e.g. cerebral palsy, cleft palate
- chronic illness e.g. crohns, CF
207
examples of inadequate retention causing weight faltering
vomiting
| severe GORD
208
examples of malabsorption leading to weight faltering
```
coeliac
CF
cows milk intolerance
short gut syndrome
previous NEC
```
209
examples of failure to utilize nutrients leading to weight faltering
```
Downs
IUGR
extreme prematurity
congenital infection
congenital hypothyroidism
```
210
examples of increased requirements leading to weight faltering
```
thyrotoxicosis
CF
malignancy
HIV/immune deficiency
congenital heart disease
```
211
definition of precocious puberty
development of secondary sexual characteristic before 8yo in females and 9yo in males
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subtypes of precocious puberty
- premature breast development (thelarche)
- premature pubic hair development (pubarche or adrenarche)
- isolated premature menarche
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risk factors for precocious puberty
- female
- exposure to CNS radiotherapy
- obesity
- afrocaribbean ethnicity
- exposure to exogenous sex hormones
214
what tool is used to help assess development of secondary sexual characteristics
Tanner staging
215
2 main mechanisms of precocious puberty
```
GnRH dependent, true precocious puberty (high LH > high FSH)
GnRH independent (low FSH and LH)
```
216
pathophysiology of GnRH dependent precocious puberty
premature activation of hypothalamic-pituitary-gonadal axis caused by:
- idiopathic (sporadic or familial) in 80% of girls and 40% of boys
- CNS abnormalities e.g. tumours, trauma, hydrocephalus
- hypothyroidism
217
pathophysiology of GnRH independent precocious puberty
increased sex hormone production not related to maturation of HPG axis - gonad matures without GnRH stimulation
- congenital adrenal hyperplasia
- tumours: HCG-secreting tumours in liver, ovarian tumour
- severe hypothyroidism
- exogenous oestrogen or androgen exposure
218
investigations in suspected precocious puberty
?GnRH dependent or independent
- head circ, weight and height
- sex steroid levels
- LH and FSH levels
- TFTs
- HCG
- US (ovaries, testes, adrenal glands)
- hand and wrist XR for bone age
- brain MRI
- GnRH stimulation test
219
what is the treatment for congenital adrenal hyperplasia
glucocorticoids
220
what is leukaemia
cancer of the blood-forming tissue, usually bone marrow, leading to overproduction of abnormal white cells
221
4 categories of leukaemia
1. acute lymphoblastic leukaemia
2. acute myeloid leukaemia
3. chronic myeloid leukaemia
4. chronic lymphoblastic leukaemia
222
which is the most common leukaemia in children
acute lymphoblastic leukaemia (78%)
223
when does acute myeloid leukaemia most commonly present
infants (<2yo)
224
which leukaemia is very rare in children
chronic lymphoblastic leukaemia
225
describe the differentiation of blood cells
stem cell differentiates into a) lymphoid stem cell or b) myeloid stem cell
a) lymphoid stem cell becomes lymphoblast which differentiates in either B or T lymphocyte
b) myeloid stem cell becomes either platelet, RBC or myeloid blast (which becomes monocyte or neutrophil)
226
when does acute lymphoblastic leukaemia most commonly present
2-3yo
227
when does chronic myeloid leukaemia commonly present
2 peaks: children <1yo and early teenage years
228
symptoms of leukaemia
- malaise, fatigue, lethargy
- prolonged/recurrent fever
- irritability
- failure to thrive
- SOB, reduced exercise tolerance
- dizziness, palpitations
- bleeding issues e.g. epistaxis, bruising
- bone/joint pain (leg)
- constipation
- prolonged cough
- headache
- nausea & vomiting
- repeated or severe childhood infections
229
signs of leukaemia due to bone marrow infiltration
- anaemia (pallor, lethargy)
- neutropaenia (infection)
- thrombocytopaenia (bruising, petechiae, epistaxis)
- bone pain
230
signs of leukaemia due to reticulo-endothelial infiltration
- hepatosplenomegaly
| - lymphadenopathy
231
signs of leukaemia due to other organ infiltration
- CNS (headaches, vomiting, nerve palsies)
| - testes (testicular enlargement)
232
investigations for leukaemia in primary care
- FBC (pancytopaenia if bone marrow is infiltrated)
| - blood film
233
investigations for leukaemia in secondary care
- bone marrow aspiration and biopsy
- imaging (extent of disease)
- immunophenotyping and cytogenic analysis
- lumbar puncture (if suspected CNS infiltration)
234
management of acute lymphoblastic leukaemia
- high-intensity chemo via central venous catheter
| - myeloablation + allogenic bone marrow transplant
235
management of acute myeloblastic leukaemia
- intensive chemotherapy
236
management of chronic myeloid leukaemia
- myeloablative haematopoietic stem cell transplantation
237
what is cerebral palsy
group of disorders causing permanent but non-progressive abnormalities of motor function and posture
238
aetiology of cerebral palsy
- damage to the immature brain: vascular, hypoxic-ischaemic, teratogenic, genetic, infective, toxin, metabolic or trauma
- most common in antenatal period (24 weeks gestation to term)
- associated with neonatal encephalopathy (HIE or sepsis)
- post-neonatal common causes are meningitis, infection and head injury
239
what area of the brain is affected in hemiplegic spastic cerebral palsy
unilateral motor cortex (arm and leg affected on one side)
240
what area of the brain is affected in diplegic cerebral palsy
bilateral medial motor cortex (both legs > both arms affected)
241
what area of the brain is affected in quadriplegic cerebral palsy
bilateral entire motor cortex (all 4 limbs)
242
what area of the brain is affected in athetoid cerebral palsy
basal ganglia
243
what area of the brain is affected in ataxic cerebral palsy
cerebellum
244
description of movement in spastic type cerebral palsy
- intermittently increased tone
| - pathological reflexes
245
description of movement in athetoid cerebral palsy
- increased activity (hyperkinesia)
| - 'stormy movement'
246
description of movement in ataxic type cerebral palsy
- loss of orderly muscle coordination
| - movements performed with abnormal force, rhythm or accuracy
247
which type of cerebral palsy is most common
bilateral (diplegia or quadriplegia) spastic type cerebral palsy
248
antenatal risk factors for cerebral palsy
pre-term birth, congenital malformations, multiple births, intrauterine infection, chorioamnionitis, toxic/teratogenic agents, maternal infection/illness
249
perinatal risk factors for cerebral palsy
low birth weight, neonatal encephalopathy, neonatal sepsis
250
postnatal risk factors for cerebral palsy
meningitis, intracranial haemorrhage, trauma, infection, hyperbilirubinaemia, hypoxia, seizures
251
developmental milestone delays which may indicate cerebral palsy
- not sitting by 8 months
- not walking by 18 months
- early asymmetry of hand function (preference) before 1 year old
252
signs of cerebral palsy which may present at 12-18 months
- abnormal posture/movement
- usual fidgety or asymmetrical movements
- abnormal tone (floppiness or stiffness)
- abnormal motor development: head control, rolling, crawling
- feeding difficulties
253
common conditions associated with cerebral palsy
- learning disability
- communication difficulties
- emotional and behavioural issues
- visual or hearing impairment
- chronic constipation
- epilepsy
254
investigations to rule out other differentials when suspecting cerebral palsy
- TFTs
- chromosomal analysis
- pyruvate and lactate levels (mitochondrial cytopathies)
- organic and amino acid levels (inborn errors)
- CSF protein, lactate and pyruvate (neonatal asphyxia)
255
4 examples of medical treatment of spasticity
1. diazepam
2. baclofen
3. botulinum toxin A
4. phenol and ethyl alcohol
256
key principles for preventing cerebral palsy
- recognition and treatment of maternal iodine
- prevention of kernicterus associated with rhesus isoimmunisation
- prolong pregnancy in preterm labour (e.g. tocolytics)
- improve neonatal ICU
257
what is ASD
autistic spectrum disorder
| developmental condition causing an impairment of social interaction, communication and flexible behaviour
258
what is Aspergers
normal intelligence and ability to function in everyday life but displays difficulties in reading emotions and responding to others
259
differentials to consider when suspecting autism
- deafness
- general learning disability
- childhood disintegrative disorder (Heller's disease)
- Rett syndrome: X-linked neurodevelopmental condition involving loss of spoken language and hand use
260
genetic risk factors for autism
- chromosomal anomalies
- affected sibling
- metabolic errors such as PKU
261
environmental risk factors for autism
- advanced prenatal age
- exposure to teratogens
- maternal diabetes
- antenatal infection: rubella, influenza
- low birth weight
- birth asphyxia
- abnormally short gestational length
262
clinical features of autism relating to social interaction
- lack of eye contact
- smiling delay
- avoiding physical contact
- inability to read non-verbal cues
- difficulty establishing friendships
- no desire to share attention e.g. playing with others
- lack of awareness of social norms
263
clinical features of autism relating to communication
- delayed, absence or regression of language development
- lack of appropriate non-verbal communication
- difficulty with imaginative or imitative behaviour
- repetitive use of words or phrases
264
clinical features of autism relating to behaviour
- greater interest in objects, number or patterns than people
- repetitive movements
- highly specific and narrow interests/hobbies
- strong preference for fixed routine
- unusual reactions to sensory stimuli
- extremely restricted food preferences
265
4 assessment tools for autism
1. autism diagnostic interview, revise (ADI-R)
2. diagnostic interview for social and communication disorders (DISCO)
3. development, dimensional and diagnostic interview
4. AQ-10 (adults)
266
diagnostic criteria for autism
6+ symptoms across all 3 areas (communication, social interaction and behaviour)
observed in different environments e.g. home, school, clinic
267
management options for autism
- behavioural and psychological interventions
- speech and language therapy
- interventions to support social skills
268
what is ADHD
attention deficit hyperactivity disorder
extreme end of hyperactivity and inability to concentrate
affects ability to carry out every day tasks, develop normal skills and perform well at school
must be consistent across various settings
269
risk factors for ADHD
- low birth weight
- preterm birth
- acquired brain injury
- epilepsy
- lead poisoning
- iron deficiency
- maternal health problems
- substance misuse
- presence of other mental health or neurodevelopmental disorders
270
2 categories of clinical features of ADHD
- inattention
| - hyperactivity and impulsivity
271
criteria for clinical features of ADHD to meet for diagnosis
- some symptoms present before 12 years of age
- some symptoms present in two or more settings
- evidence that symptoms interfere with social, school or work functioning
- symptoms not better explained by another mental disorder
272
rating scale used for adhd
conners
273
examples of medication used in ADHD
- methylphenidate (ritalin)
- dexamfetamine
- atomoxetine
